011400514-4-3-2024-15-AS-KHOS-D4MJW6-20240424072412

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 011400514
Report Date: 04/03/2024
Date Signed: 04/03/2024 05:28:35 PM

Unsubstantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

This is an official report of an unannounced visit/investigation of a complaint received in our office on
10/12/2023 and conducted by Evaluator Laura Hall

COMPLAINT CONTROL NUMBER: 15-AS-20231012170420

FACILITY NAME:	PIEDMONT GARDENS #1		FACILITY NUMBER:	011400514
ADMINISTRATOR:	WITTMAN, DANIEL		FACILITY TYPE:	741
ADDRESS:	110-41ST STREET		TELEPHONE:	(510) 654-7172
CITY:	OAKLAND	STATE: CA	ZIP CODE:	94611
CAPACITY:	321	CENSUS: 63	DATE:	04/03/2024
		UNANNOUNCED	TIME BEGAN:	04:00 PM
MET WITH:	Zinnia Koch, Director of Wellness and Assisted Living		TIME COMPLETED:	05:40 PM

ALLEGATION(S):

1
2
3
4
5
6
7
8
9

Facility neglected to provide Resident adequate basic care needs.

Facility did not follow physician's orders.

INVESTIGATION FINDINGS:

1
2
3
4
5
6
7
8
9
10
11
12
13

On 4/3/2024 at 4:00pm, Licensing Program Analyst (LPA), L. Hall arrived unannounced to deliver complaint findings for the allegations above. LPA met with Zinnia Koch, Director of Wellness and Assisted Living and explained the reason for the visit.

The Department interviewed the reporting party (RP), staff, obtained and reviewed records. The records reviewed included but not limited to physician's reports, assessments, care plans, service plans, progress notes, incident reports, medication administrator record (MAR), discharge summaries, interdisciplinary notes, and doctor orders.

Continued on LIC9099C.

Unsubstantiated

Estimated Days of Completion:

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 2

Control Number 15-AS-20231012170420

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: PIEDMONT GARDENS #1	FACILITY NUMBER: 011400514
	VISIT DATE: 04/03/2024

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Continued from LIC9099.

Allegation: Facility neglected to provide Resident adequate basic care needs.

During initial interview with RP it was stated that when R1 returned for her follow-up appointment on 9/19/2023, it appeared that R1's daily activities of daily living (ADLs) were not being met. S1 stated during interview that R1 is accompanied to her appointments by her daughter. Interview and record review indicated that R1 is bathed twice a week. S1 stated that if the health nurse (that comes once a week) bathes R1 the facility does not document it. LPA reviewed the care plans and MARs during the investigation and observed that two (2) medications were prescribed to assist R1 with basic care needs. Therefore, the facility did not neglect to provide R1 adequate basic care.

Allegation: Facility did not follow physician's orders.

RP stated facility did not follow orders that were given upon R1 being discharged from procedure. LPA observed discharge summary and physician's order for R1 during record review. Review of clinical notes indicated that on 9/14/2023, staff tried to remove dressing from wound but was not able to due to dried blood. Notes also indicated that staff would have day shift contact doctor and continue to soak wound to loosen. Staff contacted nurse on 9/15/2023, and was told to give it 1-2 more days. Staff tried again on 9/16/2023, but R1 expressed pain. On 9/17/2023, staff requested nurse. Nurse arrived on 9/18/2023. On 9/19/2023, staff called clinic to have R1 seen for dressing to be removed. R1 was seen and returned with new discharge instructions, which LPA observed during record review.

Based upon the information obtained during investigation. The above allegations are unsubstantiated. A finding that the complaint is UNSUBSTANTIATED means that although the allegation may have happened or is valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.

Exit interview conducted and a copy of report was given.

SUPERVISOR'S NAME: Harpreet Humpal	TELEPHONE: (510) 285-3928
LICENSING EVALUATOR NAME: Laura Hall	TELEPHONE: (510) 622-2024
LICENSING EVALUATOR SIGNATURE:	DATE: 04/03/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/03/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 2